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There has been a recent rise in the use of eHealth treatments for a variety of psychological disorders, including eating disorders.
This meta-analysis of randomized controlled trials is the first to evaluate the efficacy of eHealth interventions specifically for the treatment of binge eating disorder (characterized by compulsive overconsumption of food, in a relatively short period, and without compensatory behaviors such as purging or fasting).
A search on the electronic databases PubMed, Web of Science, Embase, MEDLINE, and CINAHL was conducted for randomized controlled trials that compared the efficacy of eHealth treatment interventions with waitlist controls.
From the databases searched, 3 studies (298 participants in total) met the inclusion criteria. All interventions were forms of internet-based guided cognitive behavioral therapy. The results of the analysis demonstrated that when compared with waitlist controls, individuals enrolled in eHealth interventions experienced a reduction in objective binge episodes (standardized mean difference [SMD] −0.77, 95% CI −1.38 to −0.16) and eating disorder psychopathology (SMD −0.71, 95% CI −1.20 to −0.22), which included shape (SMD −0.61, 95% CI −1.01 to −0.22) and weight concerns (SMD −0.91, 95% CI −1.33 to −0.48). There was no significant difference in BMI between the eHealth interventions and controls (SMD −0.01, 95% CI −0.40 to 0.39).
These findings provide promising results for the use of internet-based cognitive behavioral therapy for binge eating disorder treatment and support the need for future research to explore the efficacy of these eHealth interventions.
Binge eating disorder (BED) is recognized in the Diagnostic and Statistical Manual of Mental Disorders as abnormal and excessive eating patterns marked by uncontrolled, recurrent, and persistent binge eating [
BED is of particular research interest because of its frequency in primary care, its comorbidity with obesity and other medical and psychiatric disorders, and its high socioeconomic impact as a result of reduced quality of life and an increased need for patients to use health and medical services [
The current
Recently, the use of eHealth technology has been proposed as a potentially effective alternative to traditional, in-person treatment delivery for those with BED [
Many eHealth treatments for BED are in line with the CBT principles described in the self-help book
Although several studies have examined the effects of eHealth treatments on different elements of BED, including bulimia [
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines [
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart outlining the selection of studies included in the meta-analysis. BED: binge eating disorder; RCT: randomized controlled trial.
Studies used in the analysis had to meet the following prespecified inclusion criteria: (1) adult male or female participants aged 18 years and older, diagnosed with full or subthreshold BED. In the latter case, patients had to meet the criterion for objective binge episodes (OBEs) but could lack one of the other Diagnostic and Statistical Manual of Mental Disorders criteria (ie, frequency of less than 2 days with OBEs in 6 months, no marked distress, or presence of only 2 of the 5 associated criteria) [
The following data were extracted from each study: (1) first author’s last name, (2) year of publication, (3) total sample size and group size posttreatment, (4) type of treatment and control, (5) BED diagnosis status and criteria used for diagnosis, (6) mean age of participants, (7) treatment length, (8) therapist contact, (9) percentage of females in the study, and (10) mean and SD posttreatment for all outcomes in the treatment and control groups.
The overall risk of bias was assessed by 2 independent reviewers using the revised Cochrane risk of bias tool for randomized trials [
Characteristics of the studies included in the meta-analysis. Waitlist controls were compared with an internet version of cognitive behavioral therapy or guided self-help therapy. All 3 therapies use the principles of cognitive behavioral therapy and have varying degrees of therapist guidance and interaction with the patients.
Authors | Participant | BEDa diagnosis (diagnostic criteria) | Therapist contact | Females, n (%) | Age, mean (SD) | Treatment length | Risk of bias | ||||||||
|
Total, N | Treatment group, n (%) | Control group, n (%) |
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|
|
|
|
|
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Carrard et al, 2011A [ |
74 | 37 (50) |
37 (50) WLc | Full (n=43) or subthreshold (n=31) BED (eating disorder questionnaire based on DSM-IVd) | Weekly contact via email | 74 |
36 |
6 months | Low | ||||||
ter Huurne et al, 2015 [ |
85 | 43 (51) |
42 (49) WL | Diagnosed with BED (participant self-report based on DSM-IV) | Internet-based contact with the therapist twice a week | 85 |
40.2 |
15 weeks | Low | ||||||
Wagner et al, 2016 [ |
139 | 69 (50) |
70 (50) WL | Diagnosed with BED (telephone interview using DSM-5f criteria) | Internet-based contact with therapist when submitting assignments | 134 |
35.1 |
16 weeks | Low |
aBED: binge eating disorder.
bI-GSH: internet-guided self-help.
cWL: waitlist.
dDSM-IV: Diagnostic and Statistical Manual of Mental Disorders, 4th edition.
eI-CBT: internet-based cognitive behavioral therapy.
fDSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5th edition.
Postreatment results for each study.
Authors | OBEa | BMI | EDE-Qb | Shape concern | Weight concern | |||||||||
|
Treatment posttreatment, mean (SD) | Control posttreatment, mean (SD) | Treatment posttreatment, mean (SD) | Control posttreatment, mean (SD) | Treatment posttreatment, mean (SD) | Control posttreatment, mean (SD) | Treatment posttreatment, mean (SD) | Control posttreatment, mean (SD) | Treatment posttreatment, mean (SD) | Control posttreatment, mean (SD) | ||||
Carrard et al, 2011A [ |
5.5 (7.4) | 9.1 (8.8) | 29.2 (6.0) | 27.9 (5.4) | 2.5 (1.1) | 2.9 (1.0) | 3.7 (1.3) | 4.1 (1.3) | —c | — | ||||
ter Huurne et al, 2015 [ |
— | — | — | — | 2.6 (1.3) | 3.2 (0.9) | 3.5 (1.6) | 4.2 (1.1) | 3.1 (1.4) | 3.9 (0.9) | ||||
Wagner et al, 2016 [ |
6.8 (7.5) | 14.9 (7.7) | 31.4 (6.9) | 32.8 (8.3) | 2.5 (1.2) | 3.7 (0.8) | 3.4 (1.4) | 4.5 (0.8) | 3.0 (1.3) | 4.2 (0.8) |
aOBE: objective binge episode.
bEDE-Q: Eating Disorder Examination Questionnaire.
cNot available (missing data).
Given the anticipated heterogeneity, the studies were pooled using a meta-analytic random effects model. The reported
In total, 3 RCT studies met all the inclusion criteria and were included in the meta-analysis, with a total of 298 participants. All studies were consistent in the intervention and study participants and were appropriately combined in a meta-analysis. Assessment of the risk of bias scores indicated a low risk of bias in all 3 studies. Furthermore, all the studies recruited female participants, except 1 that sampled 96.4% (134/139) females [
A summary of the meta-analysis results for each included outcome is described below and summarized in
Summary of findings for the randomized controlled trial studies.
Outcome | Studies, n (%) | Participants, N | Effect size; SMDa (95% CI) | Heterogeneity, I2b (%) | |
Objective binge episodesc | 2 (67) | 213 | −0.77 (−1.38 to −0.16) | 77 | .01 |
BMI | 2 (67) | 213 | −0.01 (−0.40 to 0.39) | 50 | .96 |
EDE-Qd totalc | 3 (100) | 298 | −0.71 (−1.20 to −0.22) | 77 | .005 |
Shape concernc | 2 (67) | 298 | −0.61 (−1.01 to −0.22) | 64 | .002 |
Weight concernc | 2 (67) | 224 | −0.91 (−1.33 to −0.48) | 56 | <.001 |
aSMD: standardized mean difference.
bI2 values above 25% indicated low heterogeneity, 50% indicated moderate heterogeneity, and above 75% indicated substantial heterogeneity [
c
dEDE-Q: Eating Disorder Examination Questionnaire.
In total, 2 of the studies involving 213 participants evaluated OBE. Among the studies, one demonstrated a significant reduction in OBE in the treatment group compared with the WL control (SMD −1.06, 95% CI −1.42 to −0.70). The pooled SMD was −0.77 (95% CI −1.38 to −0.16; Figure S1 of
In total, 2 of the studies involving 213 participants evaluated BMI. None of the studies demonstrated a significant change in BMI in the treatment group compared with the WL group. The pooled SMD was −0.01 (95% CI −0.40 to −0.39; Figure S2 of
In total, 3 of the studies involving 298 participants evaluated the EDE-Q total score. Two of the studies demonstrated a significant reduction in EDE-Q scores in the treatment group compared with WL groups (SMD −1.17, 95% CI −1.53 to −0.81 and SMD −0.53, 95% CI −0.96 to −0.10). The pooled SMD was statistically significant with an estimate of −0.71 (95% CI −1.20 to −0.22; Figure S3 of
In total, 3 of the studies involving 298 participants evaluated the EDE-Q subscale of shape concern. Two of the studies demonstrated a significant reduction in shape concern scores in the treatment group compared with WL groups (SMD −0.96, 95% CI −1.31 to −0.61 and SMD −0.50, 95% CI −0.94 to −0.07). The pooled SMD was −0.61 (95% CI −1.01 to −0.22; Figure S4 of
In total, 2 of the studies involving 224 participants evaluated the EDE-Q subscale of weight concern. Both studies demonstrated a significant reduction in shape concern scores in the treatment group compared with WL groups (SMD −1.11, 95% CI −1.47 to −0.75 and SMD −0.67, 95% CI −1.11 to −0.23). The pooled SMD is −0.91 (95% CI −1.33 to −0.48; Figure S5 of
This study reports the first meta-analysis of RCTs designed to assess the efficacy of eHealth treatments for individuals diagnosed with BED. Due to its specificity, 3 studies met the inclusion criteria and were included in the analysis. All of these used an internet-based form of guided CBT therapy, wherein the degree of therapist interaction varied depending on the nature of the intervention that was administered. Due to the novelty of eHealth innovations and our study objectives, it was important to evaluate efficacy by restricting to the RCT design. Despite the limited number of studies, statistically significant results demonstrated the effectiveness of internet-based CBT, in combination with GSH treatment, in reducing binge episodes, ED psychopathology, and shape and weight concerns. Although the efficacy of conventional CBT therapy has been well demonstrated [
Despite the moderate effect of the treatment in reducing the number of OBEs, internet-based therapies did not appear to produce a significant change in BMI. Notably, the lack of substantial weight loss has long been considered one of the principal drawbacks of the current CBT therapy for BED. For instance, Peat et al [
In patients with BED, the purpose of CBT is to reduce binge eating frequency and body image dissatisfaction by altering destructive behaviors and thinking patterns, particularly those that involve eating, weight and shape, and psychosocial functioning [
In addition to exploring the efficacy of eHealth interventions, this meta-analysis highlights an important point regarding the status of eHealth and BED research. That is, despite its promising impact on improving BED symptomatology and its moderate effect in reducing ED psychopathology, there are only a small number of RCT studies that have evaluated the efficacy of eHealth treatments, and even fewer studies have compared them with the traditional, in-person method of delivery [
Despite improving the accessibility of treatment delivery, an important point that may warrant further analysis is
Since January 2019, 3 RCT study protocols have been published that outline the use of eHealth interventions for the treatment of BED [
One of the limitations of this study is its level of generalizability. The majority of participants were middle-aged women who were overweight or obese. Therefore, how well these findings can be applied to other age groups and male patients is not clear. It is important to note, however, that one of the reasons why the participant pool consists primarily of overweight and obese women may be that the disorder has a higher prevalence in females, and those diagnosed are 3-6 times more likely to be obese [
This study provides preliminary evidence that eHealth treatments, and more specifically internet-based guided CBT treatments, are appropriate treatment avenues for BED. However, because of the limited number of published RCTs in this field, it is important for the current evidence base to become more complete, so that more conclusive results can be extracted. As more findings are published in this area, future studies not only need to analyze the efficacy of eHealth treatments but to further hone in on the effectiveness of in-person versus eHealth treatments, to investigate the differences in efficacy among the different types of eHealth treatments, to evaluate which elements of the treatment result in unchanged BMI, and to determine the characteristics of patients with BED that make them more suitable candidates for this alternative form of treatment.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.
Forest plot of outcomes.
binge eating disorder
cognitive behavioral therapy
Diagnostic and Statistical Manual of Mental Disorders, 4th edition
Diagnostic and Statistical Manual of Mental Disorders, 5th edition
eating disorder
Eating Disorder Examination Questionnaire
internet-based cognitive behavioral therapy
internet-based guided self-help
Medical Subject Headings
objective binge episode
Preferred Reporting Items for Systematic Reviews and Meta-analyses
randomized controlled trial
standardized mean difference
waitlist
The study was conceived by EM, who conducted the literature search and quantitative analysis, wrote the first draft of the manuscript, and made subsequent revisions. CD and MR assisted with the revision of the manuscript and addition of literature references, and MR assisted with quantitative analysis. All authors have approved the submission of the manuscript.
EM is currently developing a mobile app that tracks psychological well-being and screens for pathological overeating in individuals who are looking to lose weight. This app is in the development phase. Although it is not a direct eHealth intervention, its tracking functionality may influence the efficacy of the treatment that the individual is undergoing. CD and MR have no conflicts of interest to declare.